HELPING YOUR PATIENTS
GET THE SLEEP
OF THEIR DREAMS
OCFP 51ST ANNUAL SCIENTIFIC
ASSEMBLY
NOVEMBER 2013
Dr. CAROLE LAMARCHE, C. Psych.
DECLARATION REGARDING
CONFLICT OF INTEREST
I DO NOT HAVE AN AFFILIATION
(FINANCIAL OR OTHERWISE) WITH A
PHARMACEUTICAL, MEDICAL
DEVICE OR COMMUNICATIONS
ORGANIZATION
copyright Dr. Carole Lamarche, C.
Psych.
OBJECTIVES OF TODAY’S
SEMINAR
PROVIDE A BRIEF OVERVIEW OF COMMON SLEEP
DISORDERS INCLUDING INSOMNIA, OBSTRUCTIVE SLEEP
APNEA, AND RESTLESS LEGS SYNDROME.
UNDERSTAND THE COMPONENTS OF COGNITIVEBEHAVIOURAL TREATMENT FOR INSOMNIA
PROVIDE EXAMPLES OF BRIEF ASSESSMENT AND
INTERVENTION STRATEGIES FOR SLEEP DISORDERS
UNDERSTAND WHEN TO REFER TO A SLEEP CLINIC OR
PSYCHOLOGIST
copyright Dr. Carole Lamarche, C. Psych.
INSOMNIA: BRIEF
ASSESSMENT STRATEGIES
FOR THE PHYSICIAN
REVIEW HEALTH HISTORY FOR
COMMON COMORBID DISORDERS:
– DEPRESSION
– ANXIETY
– SUBSTANCE USE
– PHYSICAL PAIN
– HEART AND LUNG PROBLEMS
copyright Dr. Carole Lamarche, C.
Psych.
INSOMNIA: BRIEF
ASSESSMENT STRATEGIES
FOR THE PHYSICIAN
HAVE PATIENT KEEP A SLEEP
DIARY
OBTAIN COLLATERAL INFORMATION
FROM BEDPARTNER
ASK ABOUT RECENT LIFE EVENTS
ASK ABOUT PHYSICAL PAIN
ASK ABOUT MOOD AND INTEREST
copyright Dr. Carole Lamarche, C.
Psych.
INSOMNIA: BRIEF
ASSESSMENT STRATEGIES
FOR THE PHYSICIAN
ASK PATIENTS HOW MUCH
ALCOHOL THEY USE PER DAY
ASK PATIENTS ABOUT CAFFEINE
USE
ASK PATIENTS ABOUT NAPPING
copyright Dr. Carole Lamarche, C.
Psych.
PSYCHOLOGICAL
TREATMENT OF INSOMNIA
STIMULUS CONTROL THERAPY
SLEEP RESTRICTION THERAPY
COGNITIVE THERAPY
copyright Dr. Carole Lamarche, C. Psych.
STIMULUS CONTROL
GO TO BED ONLY WHEN SLEEPY
IF UNABLE TO FALL ASLEEP OR STAY ASLEEP
WITHIN 20 MINUTES, LEAVE BEDROOM
RETURN TO BED WHEN SLEEPY
REPEAT AS OFTEN AS NECESSARY
MAINTAIN REGULAR WAKETIME
DO NOT NAP
USE BEDROOM ONLY FOR SLEEP AND SEX
copyright Dr. Carole Lamarche, C. Psych.
SLEEP RESTRICTION
ESTIMATE TOTAL SLEEP TIME
FROM SLEEP DIARY
PRESCRIBE ESTIMATED TOTAL
SLEEP TIME AS NEW TIME TO STAY
IN BED
AS SLEEP IMPROVES, ADD 15
ADDITIONAL MINUTES TO TIME IN
BED
copyright Dr. Carole Lamarche, C. Psych.
COGNITIVE THERAPY
IDENTIFY MALADAPTIVE
THOUGHTS, PREDICTIONS AND
BELIEFS ABOUT SLEEP
CHALLENGE THESE WITH FACTS
ABOUT SLEEP AND EVIDENCE
FROM PATIENT’S LIFE
copyright Dr. Carole Lamarche, C. Psych.
INSOMNIA: ADDITIONAL
PSYCHOLOGICAL
INTERVENTIONS
RELAXATION TRAINING
– PROGRESSIVE MUSCLE RELAXATION
– DIAPHRAGMATIC BREATHING
– IMAGERY AND VISUALIZATION
– AUTOGENICS
copyright Dr. Carole Lamarche, C.
Psych.
MEDICAL INTERVENTIONS
FOR INSOMNIA
MEDICATIONS
– BENZODIAZEPINES
– BENZODIAZEPINE RECEPTOR
AGONITSTS
– ANTI-DEPRESSANTS
– ANTI-PSYCHOTICS
copyright Dr. Carole Lamarche, C.
Psych.
WHAT ABOUT
MEDICATIONS?
MEDICATIONS ARE APPROPRIATE FOR
SHORT-TERM OR INTERMITTENT USE
BUT NOT FOR CHRONIC USE
MANY IMPACT SLEEP ARCHITECTURE,
HAVE ADDICTION POTENTIAL, CAN
CAUSE DAYTIME SLEEPINESS AND
CREATE REBOUND INSOMNIA UPON
WITHDRAWAL
copyright Dr. Carole Lamarche, C.
Psych.
INSOMNIA: BRIEF
INTERVENTIONS FOR THE
PHYSICIAN
ASK PATIENT TO MAKE TO-DO LIST
ASK PATIENT TO JOURNAL
HAVE PATIENT LEARN RELAXATION
ASK PATIENT TO GET OUT OF BED
WHEN AWAKE
ASK PATIENT TO GO TO BED LATER/
WAKE UP EARLIER
copyright Dr. Carole Lamarche, C.
Psych.
INSOMNIA: BRIEF
INTERVENTIONS FOR THE
PHYSICIAN
ENCOURAGE PATIENTS TO ONLY
SLEEP AND HAVE SEX IN BED,
NOTHING ELSE
ENCOURAGE A REGULAR WAKE-UP
TIME, REGARDLESS OF SLEEP
QUANTITY OR QUALITY
HAVE PATIENTS INCREASE
AFTERNOON PHYSICAL ACTIVITY
copyright Dr. Carole Lamarche, C.
Psych.
DSM-5 BREATHINGRELATED DISORDERS
OBSTRUCTIVE SLEEP APNEA
HYPOPNEA (OSAH)
CENTRAL SLEEP APNEA
SLEEP-RELATED
HYPOVENTILATION
copyright Dr. Carole Lamarche, C.
Psych.
OSAH: BRIEF ASSESSMENT
STRATEGIES FOR THE
PHYSICIAN: HISTORY
SPECIFIC
FACTORS:
– OBESITY
– CROWDED
PHARYNGEAL
AIRWAY
– AGE
– GENDER
– MENOPAUSE
COMMON
COMORBIDITIES:
– HYPERTENSION
– CORONARY
ARTERY DISEASE
– HEART FAILURE
– STROKE
– DIABETES
– DEPRESSION
copyright Dr. Carole Lamarche, C.
Psych.
OSAH: BRIEF ASSESSMENT
STATEGIES FOR THE
PHYSICIAN: HISTORY
NON-SPECIFIC FACTORS:
– MORNING HEADACHES
– HEARTBURN
– NOCTURIA
– REDUCED LIBIDO
– DRY MOUTH
– ERECTILE DYSFUNCTION
copyright Dr. Carole Lamarche, C.
Psych.
OSAH: BRIEF ASSESSMENT
STRATEGIES FOR THE
PHYSICIAN
DO THEY SNORE?
DOES A BEDPARTNER COMPLAIN
OF SNORING OR OTHER LOUD
NOISES?
DO THEY FALL ASLEEP DURING THE
DAY WITHOUT TRYING?
ANY ACCIDENTS OR NEAR MISSES?
copyright Dr. Carole Lamarche, C.
Psych.
INTERVENTIONS FOR
OBSTRUCTIVE SLEEP
APNEA HYPOPNEA
CONTINUOUS POSITIVE AIRWAY
PRESSURE (CPAP)
BILEVEL POSITIVE AIRWAY
PRESSURE (BiPAP)
ORAL APPLIANCES
POSITIONAL STRATEGIES (I.E.
TENNIS BALL)
copyright Dr. Carole Lamarche, C.
Psych.
INTERVENTIONS FOR
OBSTRUCTIVE SLEEP
APNEA HYPOPNEA
SURGERY OPTIONS:
– TISSUE REMOVAL (UPPP, TONSILS,
ADENOIDS
– JAW REPOSITIONING
– NASAL SURGERY
– IMPLANTS INTO THE SOFT PALATE
copyright Dr. Carole Lamarche, C.
Psych.
OSAH: ADDITIONAL BRIEF
INTERVENTIONS FOR THE
PHYSICIAN
ENCOURAGE HEALTHY EATING AND
PHYSICIAL ACTIVITY IN ORDER TO
PROMOTE WEIGHT LOSS
ENCOURAGE SMOKING CESSATION
ENCOURAGE MODERATION WITH
ALCOHOL USE
TREAT COMORBID MENTAL AND
PHYSICAL HEALTH CONDITIONS
copyright Dr. Carole Lamarche, C.
Psych.
RESTLESS LEGS SYNDROME
(RLS): BRIEF ASSESSMENT
STRATEGIES FOR THE
PHYSICIAN
RULE OUT OTHER CAUSES OF
MOVEMENTS:
–
–
–
–
–
–
–
ARTHRITIS
LEG EDEMA
LEG CRAMPS
PERIPHERAL ISCHEMIA
HABITUAL FOOT TAPPING
POSITIONAL DISCOMFORT
MEDICATION EFFECTS
copyright Dr. Carole Lamarche, C.
Psych.
RLS: BRIEF ASSESSMENT
STRATEGIES FOR THE
PHYSICIAN: HISTORY
SPECIFIC FACTORS:
– FEMALE GENDER
– PREGNANCY
– AGE
– FAMILY HISTORY
– IRON DEFICIENCY
– GENETIC RISK FACTORS
copyright Dr. Carole Lamarche, C.
Psych.
RLS: BRIEF ASSESSMENT
STRATEGIES FOR THE
PHYSICIAN: HISTORY
COMMON COMORBIDITIES:
– DEPRESSION
– ANXIETY DISORDERS
– ATTENTIONAL DIFFICULTIES
– CARDIOVASCULAR DISEASE
– CHRONIC RENAL FAILURE
– PERIODIC LIMB MOVEMENT DISORDER
copyright Dr. Carole Lamarche, C.
Psych.
INTERVENTIONS FOR
RESTLESS LEGS
SYNDROME
MEDICATIONS:
– DOPAMINERGICS (E.G. REQUIP
(ROPINIROLE), MIRAPEX
(PRAMIPEXOLE) AND NEUPRO PATCH
(ROTIGOTINE)
– ANTICONVULSANTS
– OPIOIDS
– MUSCLE RELAXANTS
copyright Dr. Carole Lamarche, C.
Psych.
ADDITIONAL
INTERVENTIONS FOR
RESTLESS LEGS SYNDROME
LIGHT THERAPY
STRETCHING
YOGA
RELAXATION TEACHNIQUES
copyright Dr. Carole Lamarche, C.
Psych.
RLS: ADDITIONAL BRIEF
INTERVENTIONS FOR THE
PHYSICIAN
ENCOURAGE DECREASE IN CAFFEINE,
ALCOHOL AND NICOTINE USE
ENCOURAGE USE OF MASSAGE OR
WARM BATH
ENCOURAGE USE OF HEAT OR ICE
IDENTIFY VITAMIN AND MINERAL
DEFICIENCIES (IRON, MAGNESIUM, ETC.)
copyright Dr. Carole Lamarche, C.
Psych.
WHEN TO REFER TO A
SLEEP CLINIC
WHEN YOU SUSPECT THERE IS A
SLEEP DISORDER THAT NEEDS
POLYSOMNOGRAPHY TO BE
CORRECTLY DIAGNOSED
– SLEEP APNEA
– NARCOLEPSY
– REM SLEEP BEHAVIOUR DISORDER
copyright Dr. Carole Lamarche, C.
Psych.
WHEN TO REFER TO A
PSYCHOLOGIST
WHEN YOU SUSPECT A PSYCHOLOGICAL
DISORDER THAT IS MODERATE TO
SEVERE (MOOD DISORDER, ANXIETY
DISORDER, SUBSTANCE USE DISORDER)
WHEN THE PATIENT HAS CHRONIC
PHYSICAL PAIN
WHEN THE PATIENT IS HAVING
DIFFICULTY IMPLEMENTING YOUR
SUGGESTIONS
copyright Dr. Carole Lamarche, C. Psych.
SOME USEFUL WEBSITES
Canadian Sleep Society: www.css.to
Mayo Clinic:
www.mayoclinic.com/health/insomnia
American Sleep Apnea Association:
www.sleepapnea.org
Restless Legs Syndrome Foundation:
www.rls.org
copyright Dr. Carole Lamarche, C. Psych.
USEFUL REFERENCES
SINK INTO SLEEP. 2013. J. DAVIDSON
THE INSOMNIA WORKBOOK. 2009. S.
SILBERMAN & C. MORIN
SAY GOODNIGHT TO INSOMNIA. 2009 G.
JACOBS
QUIET YOUR MIND AND GET TO SLEEP.
2013. C. CARNEY & R. MANBER
INSOMNIA 1993. C. MORIN
copyright Dr. Carole Lamarche, C. Psych.
